Perceptions and practices of menstrual hygiene management among adolescent girls and young women in an urban underprivileged area of Bengaluru, India: a qualitative study

INTRODUCTION

Menstrual hygiene management (MHM) is an essential aspect of women's health, particularly during adolescence, as it significantly impacts their physical, emotional, and social well-being. The world health organization (WHO) emphasizes the importance of menstrual hygiene in achieving gender equality and improving public health outcomes.¹ Despite this, millions of adolescent girls and women in low- and middle-income countries, including India, face challenges in managing menstruation due to limited access to adequate knowledge, hygiene products, and supportive environments.² In India, cultural taboos and misconceptions surrounding menstruation often perpetuate stigma and restrict open discussions on this natural biological process. Studies show that many girls are unaware of menstruation before menarche, leading to confusion and fear when they experience their first period.³ Additionally, the lack of affordable menstrual products and inadequate sanitation facilities in schools and public spaces further compounds the difficulties in managing menstruation effectively.⁴ Adolescence is a critical period for establishing healthy practices, including menstrual hygiene. Poor menstrual hygiene can lead to various health issues, such as reproductive tract infections, and negatively impact school attendance and academic performance. Research indicates that addressing these challenges requires not only access to affordable menstrual products but also targeted interventions to raise awareness and promote positive perceptions of MHM.⁵ This qualitative study explores the perceptions and practices regarding MHM among adolescent girls and young women residing in Austin Town, Bengaluru, Karnataka. By capturing their lived experiences, the study aims to identify barriers to effective MHM and highlight opportunities for targeted interventions to improve awareness, access, and support systems in urban settings.

METHODS

This qualitative study employed FGDs as the primary data collection method to explore MHM among adolescent girls and young women. Data collection was conducted between March and April 2023, following ethical approval from the institutional ethics committee (IEC study ref No. 110/2023).

Study setting

The study was conducted in two urban locations within Austin Town, Bengaluru: Neelasandra and Maya Bazar. These areas represent underprivileged communities, providing a relevant context for examining MHM practices, cultural taboos, and barriers to effective menstrual hygiene among adolescent girls and young women aged 13 to 30 years.

Participant selection

Purposive sampling was employed to recruit females aged 13-30 years from the selected urban areas. A total of 6 FGDs, each consisting of 8-12 participants, were conducted until data saturation was achieved. Written informed consent was obtained from all participants, and parental consent and assent were also obtained for minors (under 18 years of age). The discussions were audio-recorded, and transcriptions were made for subsequent analysis.

Topic guide

A structured topic guide was developed to explore participants' knowledge, practices, social support, and cultural beliefs regarding MHM. The guide focused on several key areas: awareness of menstruation, menstrual hygiene practices, cleaning and disposal of menstrual products, and sanitation at home and school. It also explored views on cleaning external genitalia during menstruation and perceptions of various MHM products, including cloth pads, sanitary pads, tampons, and menstrual cups, with regard to their comfort, cost, environmental impact, and availability.

Further, the guide addressed menstrual practices such as isolation or taking leave from school during menstruation, frequency of product changes, challenges like discomfort or infections, and issues faced with MHM during school hours. It also examined cultural taboos, the role of family influence, and opinions on involving boys and men in MHM discussions.

Data collection and analysis

FGDs were conducted in Kannada by the principal investigator (PI), who is familiar with the cultural context of the participants. Each discussion lasted 45 to 60 minutes, and audio recordings ensured accurate transcription. Data collection continued until thematic saturation was reached, indicating that no new themes were emerging from the discussions.

Thematic analysis with inductive coding was employed for data analysis. The PI and co-investigator manually coded the data and identified key themes and subthemes on MS excel and MS word.

RESULTS

A total of 20 adolescent girls (aged 13-19 years) and 30 young women (aged 20-30 years) participated in the study. The key themes identified from the data are presented in the coding tree shown in Figure 1.

Adolescent girls and young women primarily learned about menstruation from family members, such as mothers or older sisters, and through school education. While some were well-informed before menarche, others were unaware until they experienced their first period. Most participants reported that menstrual hygiene practices, including handwashing and regular changing of sanitary products, were emphasized during their education.

"I was unaware until I got my first period." (Participant from FGD Maya bazar 3).

"My mom taught me about menstruation before it happened."(Participant from FGD Neelasandra 1.

Hygiene

Participants highlighted the importance of maintaining hygiene during menstruation, with most practicing regular changing of pads and washing hands. Most participants emphasized maintaining personal hygiene during menstruation by regularly changing sanitary products, washing their external genitalia with soap and water, and taking daily baths. Some participants perceived cloth pads as unhygienic, while a few preferred them due to affordability and comfort.

"I wash my private parts with V Wash and water." (Participant from FGD Maya bazar 1)

"I take bath every day and keep myself clean and change pads regularly." (Participant from FGD Maya bazar 1)

"I do not think it is good to use cloth pads as you can get infection." (Participant from FGD Maya bazar 1)

"I feel very comfortable using cloth pads as I do not have a problem washing it with water and soap and drying it in the sun. I feel it is healthy and less costly compared to sanitary napkins. I later burn the cloth after 2 months of usage." ."(Participant from FGD Neelasandra 1)

Sanitation

While some girls had access to clean washrooms at home, school washrooms were considered less hygienic, though still manageable. Concerns about proper sanitation were common, especially regarding the cleanliness of shared public facilities.

"The school toilets aren’t always clean, but I make it work." (Participant from FGD Maya bazar 2)

"I don’t like using toilets at school." ."(Participant from FGD Neelasandra 1)

Absenteeism

The study revealed that while some girls still reported taking leave from school due to severe menstrual pain, there was a general trend away from isolating oneself during menstruation. Girls felt that missing school was only necessary in extreme cases of discomfort.

"I take leave if the pain is severe." (Participant from FGD Maya bazar 2)

"I was isolated for 15 days after attaining menarche, told not to look at others." (Participant from FGD Neelasandra 1)

Activity engagement

Engagement in physical activities, including sports and exams, was generally unaffected by menstruation, though some girls mentioned avoiding activities on particularly painful days. The majority felt comfortable continuing their daily routines without significant disruptions.

"I continue my usual routine, including school and household work." (Participant from FGD Neelasandra 1)

"I skip sports on days with severe abdominal pain." (Participant from FGD Neelasandra 2)

Lack of autonomy

Decision-making around menstrual product usage was often dictated by family members, particularly mothers. Many girls felt they did not have much say in the products they used, although a few had made personal choices to switch products based on comfort or health concerns.

"My mom told me to use sanitary pads, and I follow it." (Participant from FGD Maya bazar 3)

"My sister introduced me to pads, and that’s what I use” (Participant from FGD Neelasandra 3)

Post-menarche rituals

Cultural rituals around menarche were reported, with girls receiving specific foods or undergoing special practices. Many were given specific foods such as sweets, raw egg, sesame oil, and the local delicacy "puttu." Post-menarche isolation practices were noted among a few.

"I was given sweets and urad dal vada after my first period." (Participant from FGD Neelasandra 2)

"I’m not allowed to pick weights or go to temples during menstruation." (Participant from FGD Maya bazar 3)

Social restrictions

Some cultural restrictions were noted, including prohibitions on menstruating girls carrying babies, participating in religious practices such as praying, touching plants, and interacting with boys during menstruation.

"We avoid carrying babies during menses." (Participant from FGD Maya bazar 3)

"I can’t go to the temple during my periods." (Participant from FGD Maya bazar 1)

Dietary taboos

Certain foods were believed to affect menstrual health, with some participants avoiding items like papaya due to concerns about excessive bleeding, while others consumed foods like pineapple, which was considered beneficial for menstrual health.

"We don’t eat papaya during periods because it increases bleeding." (Participant from FGD Maya bazar 2)

"We avoid non-veg, as it’s considered to be ‘heat food’ during menses." (Participant from FGD Neelasandra 2)

Emotional and practical support

Support from family members varied. While some girls received emotional and practical support, such as help from siblings or partners with carrying heavy loads, others felt a lack of concern regarding their menstrual needs. Practical support in the form of sanitary products was available in some schools, though not universally. Many girls had to rely on their own preparation, carrying sanitary products with them to school. Opinions about involving boys in menstruation-related discussions were mixed. While some believed it was inappropriate, others felt that boys' awareness would foster empathy and support.

"My sister helps me carry heavy things when I’m on my period." (Participant from FGD Neelasandra 1)

"My mom makes sure I rest and doesn’t let me do any work during my periods." (Participant from FGD Maya bazar 2)

"It's wrong for boys to know about this." (Participant from FGD Maya bazar 3)

"Yes, boys should know about it. Only then will they understand the pain and suffering we girls face and help us. They will also not come near us." (Participant from FGD Neelasandra 2)

DISCUSSION

The study highlights several gaps in MHM among adolescent girls and young women in low-income urban settings. A key finding is that most participants learned about menstruation from family members or school, but some lacked prior knowledge before menarche, emphasizing the need for early, culturally sensitive education.⁶ While most participants practiced good hygiene, disparities were observed in the acceptance of menstrual products, particularly cloth pads. Some girls saw them as unhygienic, while others preferred them for their affordability and comfort, reflecting socio-economic barriers to accessing commercial sanitary products.⁷

Awareness of newer menstrual products, such as menstrual cups, is growing but remains limited. The promotion of cloth pads for their environmental sustainability offers an eco-friendly alternative to disposables but must be accompanied by proper hygiene education to avoid health risks.⁸ Sanitation, especially at school, was another major concern. Poor hygiene in school washrooms was a barrier to effective MHM, supporting the need for improved sanitation infrastructure to reduce absenteeism and enhance participation in education.^9,10

While absenteeism due to menstrual pain was minimal, cultural taboos like menstrual isolation and restrictions on physical activities were still prevalent. These taboos, which contribute to the stigma around menstruation, hinder gender equality and girls’ participation in daily activities.^11,12 Furthermore, many participants reported a lack of autonomy in choosing menstrual products, as decisions were often made by family members. This finding underscores the need for public health initiatives that empower girls to make informed decisions about their menstrual health.^13,14

Cultural and dietary taboos were also significant, with beliefs about certain foods exacerbating menstrual symptoms. These taboos contribute to psychological stress and restrict girls’ participation in normal activities.¹⁵ Family support varied, with some girls receiving ample assistance while others faced difficulties in accessing products, highlighting the need for policy interventions to ensure consistent access to menstrual products in schools and communities.

Finally, mixed attitudes toward involving boys in menstruation discussions were noted. While some girls found it inappropriate, others felt male involvement could reduce stigma and foster empathy. Engaging boys and men in menstrual health education can help break gender-based taboos and promote gender equality.¹⁶

CONCLUSION

This study highlights critical gaps in MHM in low-income urban communities, emphasizing the need for early, culturally sensitive education, better access to hygienic products, and improved sanitation, particularly in schools. Addressing these issues aligns with SDGs 4 (Quality education), 5 (Gender equality), and 6 (Clean water and sanitation). Public health interventions should empower girls to make informed choices, challenge cultural taboos, and ensure equitable access to products. Involving boys and men in menstrual health education can help reduce stigma and foster inclusivity, supporting global goals for gender equality and well-being.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee St. John's Medical College and Hospital (IEC Study Ref No. 110/2023).

REFERENCES

1. 1. World Health Organization. Menstrual health. 2022. Available at: https://www.who.int. Accessed on 28 January 2025.
2. 2. UNICEF. Guidance on menstrual health and hygiene. 2019. Available at: https://www.unicef.org. Accessed on 28 January 2025.
3. 3. Dasgupta A, Sarkar M. Menstrual hygiene: How hygienic is the adolescent girl? Indian J Community Med. 2008;33(2):77-80.
4. 4. Sommer M, Caruso BA, Sahin M, Calderon T, Cavill S, Mahon T, et al. A time for global action: Addressing girls' menstrual hygiene management needs in schools. PLoS Med. 2015;12(2):e1001962.
5. 5. Garg S, Sharma N, Sahay R. Socio-cultural aspects of menstruation in an urban slum in Delhi, India. Reprod Health Matters. 2012;10(19):16-25.
6. 6. Sumpter C, Torondel B. A systematic review of menstrual hygiene management in low-income countries. PLoS One. 2013;8(1):e62004.
7. 7. Jain S, Sharma M. Exploring menstrual hygiene practices and associated factors among adolescent girls in rural areas of India. J Health Soc Behav. 2018;59(3):343-58.
8. 8. Said S, Ansari MS, Rahman MM. Environmental sustainability of cloth pads: A viable alternative to disposable sanitary products. J Environ Manage. 2020;253:109762.
9. 9. Sharma A, Awasthi A. Eco-friendly menstrual products: The promise and challenges of sustainable menstruation. Environ Sci Pollut Res. 2019;26(16):16442-50.
10. 10. Sahin M, Arslan A. Menstrual hygiene management and its association with school attendance and academic performance. Health Educ Res. 2017;32(5):379-90.
11. 11. Das P, Baker KK. Menstrual hygiene practices, WASH access, and the risk of urogenital infection in women in low-resource settings: A systematic review. Int J Environ Res Public Health. 2015;12(6):7227-55.
12. 12. Mathur S, Dhanraj A. Menstrual practices and restrictions among adolescent girls: A study from rural India. Int J Reprod Med. 2014;2014:1-6.
13. 13. Sen G, Ostlin P. Unequal, unfair, ineffective, and inefficient: Gender inequality in health: Why it exists and how we can change it. Glob Public Health. 2007;2(1):1-18.
14. 14. Santhya KG, Jejeebhoy SJ. Transition to adulthood and health outcomes among adolescents in low- and middle-income countries. Asian Popul Stud. 2015;11(1):22-40.
15. 15. Kadir MM, Rahman S. The impact of cultural beliefs and practices on menstrual hygiene among adolescent girls in Bangladesh. J Public Health. 2014;35(3):332-41.
16. 16. Prusty RK, Sahoo S. Menstrual hygiene practices and their impact on reproductive health in India: A review of studies. Int J Health Sci. 2016;10(3):413-25.